Payments for Influenza vaccine CPT codes

Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its administration once in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of additional pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal vaccination status. Medicare provides coverage for these vaccines and their administration with no co-pay or deductible.

Remember – Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a Part D covered drug.

Effective for dates of service on or after August 1, 2012, the Medicare Part B payment allowance for:

CPT 90655 is $16.456

CPT 90656 is $12.398

CPT 90657 is $6.023

HCPCS Q2035 (Afluria®) is $11.543

HCPCS Q2036 (Flulaval®) is $9.833

HCPCS Q2037 (Fluvirin®) is $14.051

HCPCS Q2038 (Fluzone®) is $12.046

Note: The Medicare Part B payment allowance for HCPCS Q2034 (Agriflu®) and HCPCS Q2039 (Flu Vaccine Adult – Not Otherwise Classified) will be determined by the local claims processing contractor.

Payment for the following may be made if the local claims processing contractor determines its use is medically reasonable and necessary for the beneficiary:

CPT 90654 (Flu vaccine, Intradermal, Preservative free (Fluzone ID®));

CPT 90660 (FluMist®, a nasal influenza vaccine); or

CPT 90662 (Fluzone High-Dose®).

Effective for dates of service on or after August 1, 2012, when payment is based on 95 percent of the AWP, the Medicare Part B payment allowance for:

CPT 90654 is $18.981

CPT 90660 is $23.456

CPT 90662 is $30.923

Reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8047.pdf